Last year Assemblyman Adam Gray, D-Merced, introduced and successfully passed Assembly Bill 1244 to crack down on medical providers who defraud the system. AB 1244 provides that If a vendor is convicted of fraud, then they are automatically suspended from treating in workers’ compensation, and the Administrative Director is to create a list of all names of suspended vendors on their website.
Last week, the Department of Industrial Relations, using new powers from Gray’s bill, announced that seven Southern California medical providers had been suspended from treating workers’ compensation payments for fraudulent billings.
As AB 1244 was moving through the process last year, Gray inserted and then quickly removed other language that seemingly relieved employers and insurers of responsibility for some small claims for “cumulative trauma” – injuries that accumulate over months or years, rather than stem from one incident.
This year he has introduced Assembly Bill 221, a new Gray bill that’s similar in thrust to last year’s abandoned language. The proposed law, if passed, will add the following language to Labor Code section 4600 that defines medical care.
(i) For claims of occupational disease or cumulative injury filed on or after January 1, 2018, the employee shall have no liability for payment for medical treatment and the employer shall have no liability for payment for medical treatment unless one or more of the following has occurred:
(1) The treatment was authorized by the employer.
(2) The injury to the body part or body parts for which the treatment was provided has been accepted by the employer.
(3) The appeals board, after an evidentiary hearing or stipulation of the parties, finds the injury to the body part or body parts for which the treatment was provided was compensable.
(4) The employee has undergone an evaluation by a qualified medical examiner, pursuant to Section 4600, or an agreed medical examiner and the evaluating physician has determined that the claimed occupational disease or cumulative injury was caused, in whole or in part, by the employment.
According to the Sacramento Bee, Gray’s office says it’s just another effort to crack down on fraud, but lobbyists who work the issue believe there are other motives.
Companies that represent medical providers in seeking workers’ compensation payments for patients’ bills have labeled it a maneuver by employers and/or insurers to shed liability.
Another theory is that it’s an indirect slap by workers’ compensation lawyers against labor unions for their 2012 deal with employers. The California Applicants Attorneys Association, however, denies paternity.
Labor killed last year’s language and will probably kill AB 221. Whatever its origin or fate, it indicates that in the next round of “reform,” cumulative trauma may be on the table.
Cumulative trauma claims have been increasing rapidly and employers and insurers see them as fraught with fraud, while unions are leery of any changes that could deny legitimate claims.m